Evolving treatment of locoregional metastatic melanoma
Faut, Marloes
DOI:
10.33612/diss.93011206
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Publication date:
2019
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Faut, M. (2019). Evolving treatment of locoregional metastatic melanoma. University of Groningen.
https://doi.org/10.33612/diss.93011206
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Marloes Faut Rianne M Heidema Harald J Hoekstra Robert J van Ginkel Lukas B Been Schelto Kruijff
Barbara L van Leeuwen
Abstract
Background: Inguinal lymph node dissection (ILND) for stage III melanoma is
accompanied by high wound complication rates. During the past decades several changes in perioperative care have been instituded to decrease the incidence of these complications. The aim of this study was to evaluate the effect of these different care protocols on wound complications after ILND.
Methods: A retrospective analysis of prospectively collected data was performed
concerning 240 patients, who underwent an ILND in the University Medical Center Groningen between 1989 and 2014. Four groups with different treatment protocols, were analysed (A: ≥ 10 days bed rest, with Bohler Braun splint, B: 10 days bed rest without splint, C: 5 days and D: 1 day of bed rest). The effect of early mobilization, abolishment of the Bohler Braun splint and postural restrictions and the introduction of prophylactic antibiotics were analysed.
Results: One or more wound complication occurred in 51.2%. Which consisted of
wound infection (29.8%), seroma (21.5%), wound necrosis (13.6%) and hematoma (5%). In consecutive periods wound complications occurred respectively in 44.4%, 60.3%, 44.9% and 55.2% of the patients. None of the instituted changes in protocols led to a decrease in wound complications.
Conclusion: Changes in perioperative care protocols did not affect the rate of
wound complications. Perhaps a change in the surgical procedure itself can lead to the necessary reduction of wound complications after ILND.
Introduction
For stage III melanoma patients, regional lymph node (LN) dissection is the standard surgical therapy after a positive sentinel LN biopsy (completion LN dissection, CLND) or clinically palpable LNs (therapeutic lymph node dissection, TLND). Unfortunately, over the decades lymph node dissection of the inguinal region (ILND) has been associated with high rates of wound complications, with rates of wound infection (WI), seroma and wound necrosis as high as 46%.1-4 The
literature on predictive factors for postoperative early wound complications (wound complications) is scarce and sometimes contradictory. Factors such as age, BMI, smoking and comorbidities, as well as the influence of palpable nodal disease and the duration of postoperative bed rest all have been analyzed extensively.2,4-8 In the
early 1970s, it was hypothesized that strict bed rest with use of a Bohler Braun splint in the postoperative period, would lead to edema reduction and a decreased tension on the wound, with a potential lower incidence of wound complications. However, treatment protocols regarding duration of postoperative bed rest and the use of a Bohler Braun splint have changed over time at our institution. Postoperative bed rest duration was reduced to increase cost-effectiveness and to decrease the incidence of venous thrombotic events. Subsequently from 2004 onward at our institution, prophylactic perioperative antibiotics have been introduced aimed at decreasing infection rates in CLND’s. This retrospective review of prospectively collected data aimed to evaluate the different peri- and postoperative protocol adjustments over the years and to evaluate their influence on wound complications in a tertiary melanoma referral centre.
Material and methods
The University Medical center Groningen (UMCG) is a melanoma referral centre. Patients who underwent an ILND for stage III melanoma between 1989 and 2014 were included in a database. The surgical procedure was either a superficial LN dissection or a combined superficial and deep LN dissection. Data were collected concerning patient characteristics, tumor characteristics, the operation procedure and the postoperative period.
A single elliptical incision was used over the femoral triangle and skin was resected along with the superficial specimen. The superficial specimen consisted of fat and subcutaneous tissue between Scarpas fascia and the muscular layer. The saphenous vein was always transected. For the combined dissections, the inguinal ligament was divided for entrance to the deep pelvis. The deep dissection was performed along the external iliac artery. A Sartorius flap was used and 2 vacuum drains were left behind.1,2
During the entire study period the same disinfectant, Chloride Hexidine was used. Since 2007, a door movement protocol was instituted, and door movements during surgery have been strictly limited to necessary door movements. Temperature in the operating room is always kept at 18°C.
Histological examination of sentinel LNs was performed with haematoxylin-eosin (HE) staining. If H&E-staining was positive, a combined superficial and deep LN dissection was performed. In case of a negative H&E-staining, immunohistochemical (IHC) staining for the protein S100 and HMB45 was performed. If IHC-staining was positive, the patient was considered solely for a superficial LN dissection from 2002 onward. For patients with positive IHC-staining who underwent a CLND, an additional deep LN dissection was performed if additional positive LNs were found in the dissected specimen. From 2004 onward, prophylactic perioperative antibiotics (1000 mg of cefazolin intravenously) were administered for all patients scheduled for a CLND. Patients with more than three involved nodes, or a LN metastasis
larger than 4cm, or extra capsular extension of tumor growth received adjuvant radiotherapy (48Gy in 20 fractions, given during a maximum of 30 days) with or without trial participation.9
Wound complication was defined as a wound complication within 30 days after the ILND. These wound complications were divided into four categories: 1: wound infection requiring antibiotics and/or surgical intervention, 2: wound necrosis which induced secondary wound healing and/or required surgical intervention, 3: seroma formation that required needle aspiration and 4: hematoma requiring surgical intervention. Seroma was defined as a fluctuating swelling in the inguinal area, hematoma as a (fluctuating) swelling in the inguinal area caused by a bleeding. An inguinal hernia requiring surgical correction, erysipelas, urine tract infection, partial neuropraxia, urinary retention, pulmonary embolism and delirium were defined as “other complication”. Four perioperative care protocols were used over the years: group A: ≥10 days bed rest, with Bohler Braun splint, group B: 10 days bed rest without splint, group C: 5 days of bed rest and group D: 1 day of bed rest. These groups correspond with the following time periods 1989-2000, 2001-2005, 2006-2011, 2012-2014. The vacuum wound drains were removed after a minimum of 7 days and if production was less than 20ml per 24 hours. Patients were prescribed support stockings for the first 6 months and low molecular weight heparin subcutaneously (2850IU of Fraxiparine) during immobilization.
Statistical analysis was performed with IBM SPSS version 22.0 (IBM, inc, Chicago, IL). For continuous variables, one-way analysis of variance (ANOVA) or the Kruskall-Wallis test was used. Differences between nominal variables were analyzed using Chi square test. Variables with a 20% significance level in the univariate logistic regression were entered in the multivariate regression. Variables with a p value lower than 0.05 in the multivariate logistic regression were identified as significant factors associated with wound complications. The following variables were analysed for their potential association with wound complications according to the literature: age, gender, smoking, BMI (<25 VS 25-30 VS >30), comorbidity (diabetes mellitus, pulmonary disease and cardiovascular disease), CLND versus TLND and nodal yield. The expected nodal yield was 8-10 nodes for a superficial dissection and 4-6 LNs for the deep dissection. The nodal yield was entered as a categorical variable (0-16
LNs, 17-22 LNs and >22 LNS). Patients with a superficial dissection only, were not included in the nodal yield analysis. Details of the operation included: operation time (≤130 min VS >130 min)and superficial versus combined dissection. Operation time was defined as the time from skin incision until skin closure. Melanoma specific survival (MSS) and disease free survival (DFS) were calculated with a Kaplan-Meier analysis. Survival was compared between patients with and patients without a wound complication and patients with and patients without a WI. The primary endpoint was the occurrence of early (≤30 days) postoperative wound complications in patients after ILND.
Institutional review board approval was achieved and the study was conducted according to the declaration of Helsinki.
Results
The study included 244 ILNDs for 239 patients (114 males and 125 females) with a median age of 56 years (range 5-91 years). The general clinicopathological characteristics are summarized in Table 1. The majority of patients (95%) underwent a combined superficial and deep ILND. Two patients underwent a concurrent bilateral ILND. Three patients underwent a bilateral superficial and deep ILND in two separate surgical procedures.
Table 1 Patient characteristics
Characteristic n % Median Range
Gender Male 114 47.7 Female 125 52.3 Age, in years a 56 5-91 Localization of primary tumor Trunk 25 10.5 Genital area 4 1.7 Thigh 70 29.3 Lower leg 73 30.5 Foot 44 18.4 Mucosal 1 0.4 Unknown primary 22 9.2 Histology of primary Superficial spreading 96 39.7 Nodular melanoma 49 20.2 Acrolentigenous 23 9.5 Unknown primary 22 9.2 Otherb 17 7.0 Breslow thickness 2.5 0.6-27 T1: ≤1.00 19 7.9 T2:1.01-2.00 62 25.9 T3: 2.01-4.0 81 33.9 T4: >4.0 53 22.2 Unknown primary 22 9.2 Ulceration Yes 89 37.2 No 116 48.5 Unknown primary 22 9.2 Comorbidity BMI>25 c 137 57.3 Smoking, current 64 26.8 ≥1 comorbidity d 83 34.7 Diabetes mellitus 18 7.5 Cardiac disease 46 19.2 Vascular disease 38 15.9 Pulmonary disease 19 7.9
Indicatione
Micrometastasis 75 31
Macrometastasis 167 69
Type dissection
Superficial and deep 230 95
Superficial 12 5
Radiotherapy < 3months f
Yes 65 26.9
No 168 69.4
Unknown 9 3.7
BMI body mass index a. Age at lymph node dissection.
b. Other is defined as verrucus, spitzoid, epitheloid, desmoplastic melanoma and lentigo maligna melanoma. c. Patients with ≥ 1comorbidity including cardiac and/or vascular and/or pulmonary disease and/or diabetes mellitus. d. Macrometastasis is defined as a palpable inguinal lymph node; micrometastasis is defined as tumor load in the sentinel node.
e. Radiotherapy started within 3 months after lymph node dissection
Overall, one or more wound complications occurred after 124 (51.2%) of the ILNDs. Wound infection was the most frequent complication(n=72; 29.8%), followed by seroma (n=52; 21.5%), wound necrosis (n=33; 13.6%) and hematoma (n=12; 5%). Antibiotics were prescribed for 72 patients (29.8%) postoperatively. Of these patients, 72 experienced a WI and 4 had another infection such as an urine tract infection. Erysipelas was encountered during the 30-day postoperative period by 19 patients (7.9%). Surgical intervention was performed for seroma, hematoma or an abscess for 49 patients (20.2%). Two patients (0.8%) suffered from postoperative bleeding which required re-exploration. One patient died of a cardiac arrest during hospitalization. Other complications occurred for 48 patients, the majority of which were erysipelas, urine retention, urine tract infection and inguinal hernia. Three patients (1.2%) experienced a pulmonary embolism within 3 months after surgery despite using prophylactic subcutaneous heparine. No deep venous thrombosis was seen. Two patients were overweight. The duration of bed rest in these patients were respectively 5, 8 and 10 days. We observed no thromboembolic events in the group with a short period of bed rest.
More than half of the patients (57.3%) had a BMI higher than 25kg/m2, and 34.7% of patients had more than one comorbidity. Postoperative radiotherapy was performed for 65 patients (26.9%), within 3 months after the ILND. Eight patients (3.3%) missed adjuvant radiotherapy due to postoperative wound complications.
The differences between the four perioperative care protocols are presented in Table 2. After the introduction of SLNB, TLND was performed less frequently during the different periods (p=0.020).
Prophylactic antibiotics in the CLND group had no impact on the incidence of wound complications (p=0.143) nor on the incidence of postoperative WIs (p=0.830). The institution of the door movement protocol in 2007 did not lead to a reduction in WIs (p=0.180). The occurrence of wound complications did not differ between the different perioperative care protocol groups (p=0.173) nor between CLND and TLND (p=0.499). The extent of the dissection (superficial + deep VS superficial) did not influence the incidence of wound complications (p=0.496). Operating time did not differ significantly between CLND and TLND (p=0.187).
Table 2. Comparison of clinicopathological char
acteristics between different care protocols (n=239)
Char acteristic A: 1989-2000 B: 2001-2005 C: 2006-2011 D: 2012-2014 p n=63 % n=78 % n=69 % n=29 % Age median (r ange ) 55(20-80) 54.5(22-86) 59(5-91) 59(20-74) 0.453 ≤55 33 52.4 41 52.6 29 42 12 41.4 >55 30 47.6 37 47.4 40 58 17 58.6 Gender 0.687 Male 30 47.6 40 51.3 29 42 15 51.7 Female 33 52.4 38 48.7 40 58 14 48.3 Smoking, current 0.347 -43 68.3 57 73.1 50 72.5 25 86.2 + 20 31.7 21 26.9 19 27.5 4 13.8 Histology of primary <0.001 Superficial spreading 14 22.2 29 37.7 40 58 12 41.4 Nodular melanoma 12 19.0 11 14.3 16 23.2 8 27.6 Acrolentigenous 7 12.7 10 13.0 2 2.9 3 10.3 Unknown primary 7 11.1 8 10.3 5 7.2 2 6.9 Other* 3 4.8 6 7.8 4 5.8 4 13.8 BMI median (r ange ) c 26(18.7-39.1) 26(20.2-39.8) 25.1(13.5-53.9) 26(20.2-36.8) 0.151 <25 25 41.0 27 36.0 33 48.5 11 37.9 25-30 30 49.2 39 52.0 24 35.3 10 34.5
>30 6 9.8 9 12.0 11 16.2 8 27.6 Diabetes Mellitus 0.347 -60 95.2 74 94.9 61 88.4 26 89.7 + 3 4.8 4 5.1 8 11.6 3 10.3 ≥ 1 comorbidity d 0.332 -42 66.7 55 70.5 44 63.8 15 14 + 21 33.3 23 29.5 25 36.2 14 48.3 Indication 0.020 Micrometastasis 18 28.6 17 21.8 25 36.2 15 51.7 Macrometastasis 45 71.4 61 78.2 44 63.8 14 48.3 OR time, median (r ange ) e 135(40-285) 141(68-254) 125(50-248) 130(70-195) 0.168 ≤130 minutes 31 49.2 30 38.5 39 56.5 15 51.7 >130 minutes 32 50.8 48 61.5 30 43.5 14 48.3 postoper ativ e hospital sta y, median (r ange ) f 14(7-34) 13(8-45) 8(5-47) 6(4-14) <0.001 Radiother ap y 0.823 no 42 72.4 55 73.3 46 67.6 22 75.9 ye s 16 27.6 20 26.7 22 32.4 7 24.1 ≥1wound complication 0.173 -35 55.6 31 39.7 38 55.1 13 44.8 + 28 44.4 47 60.3 31 44.9 16 55.2 W ound infection 16 24.5 22 28.2 22 31.9 12 41.4 0.448 Seroma 13 20.6 18 23.1 12 17.4 9 31 0.500 Hematoma 0 0 5 6.4 2 2.9 4 13.8
Necrosis 6 9.5 20 25.6 4 5.8 3 10.3
Complication grade I-II
25 71.4 50 76.9 27 67.5 17 60.7 0.333
Complication grade III
10 28.6 15 23.1 13 32.5 11 39.3 0.093 ≥1 other complication 0.613 -51 81 62 79.5 58 84.1 21 72.4 + 12 19 16 20.5 11 15.9 8 27.6
Total nodal yield
0.003 0-16 34 73.9 46 64.8 25 43.1 11 42.3 17-22 10 21.7 17 23.9 18 31 6 23.1 >22 2 4.3 8 11.3 15 25.9 9 34.6
BMI body mass inde
x, OR oper ating r oom Gr oup A is defined as patients with Bohler Br aun splint, bed rest ≥ 7 days. Gr oup B, C and D include patients with the leg elev ated, without Bohler Br aun splint. Gr oup B: ≥ 7 days bed r est. Gr
oup C is defined as bed r
est of 5 or 6 days. Gr
oup 4 ar
e patients with 1-4 days of bed r
est.
a. p-v
alues <0.05 ar
e in bold
b. Other is defined as v
errucus, spitzoid, epitheloid, desmoplastic melanoma and lentigo maligna melanoma.
c. P
atients with ≥ comorbidity including car
diac and/
or v
ascular and/
or pulmonary disease and/
or diabetes mellitus
d.
Gr
ades ar
e for surgical complications, 1-II mild-moder
ate (
observ
ation or antibiotics), III sev
er e (surgical interv ent ion) Multivariate analysis re vealed increasing age to be associated with the occurrence of wound complications OR1.03 (per y ear), p=0.035, as shown in T able 3.
Table 3 Univariate and multivariate analysis of characteristics associated with ≥1 postoperative complication ( n= 124)
Characteristic ≥1 complications Multivariate
OR p (95% CI) (%) Univariate, p Age, median(range) 58.5 (22-91) <0.001 1.03, 0.035 (1.00-1.05) <55 1.00 >55 2.16, 0.003 Gender Male 65/116 56 0.153 1.71, 0.072(0.95-3.14) Female 59/126 46.8 Histology of primary 0.415 Superficial spreading 47 37.9 Nodular 25 20.2 Acrolentigenous 12 9.7 Unknown primary 11 8.9 Other 6 4.8 BMI 0.018 <25 40/98 40.8 1.00, 0.242 25-30 61/104 58.7 1.63, 0.136 (0.86-3.10) >30 20/34 58.8 1.78, 0.236 (0.76-3.00) Smoking - 89/176 50.6 + 35/66 53 0.733 ≥1 comorbidity - 69/159 43.4 + 55/83 66.3 0.001 1.51, 0.236 (0.76-3.00) Operative time ≤130 minutes 52/117 44.4 > 130 minutes 72/125 57.6 0.041 1.61, 0.107 (0.90-2.88) OR year 0.667 1989-2000 28/63 44.4 2001-2005 48/80 60 2006-2011 31/69 44.9 2012-2014 17/30 56.7
Bohler Braun Splint
Yes 28/63 44.4 0.211
Bed in Linido Yes 66/120 54.1 0.246 No 58/122 47.5 Type dissection 0.499 Superficial 5/12 41.7 Superficial+ deep 119/230 51.7 Indication 0.499 Micrometastasis 36/75 48 Macrometastasis 88/167 52.7
Total nodal yield 0.180
0-16 60/127 47.2 1.00, 0.767
17-22 28/51 54.9 1.00, 0.998 (0.49-2.03)
>22 20/34 58.8 1.35, 0.482 (0.59-3.07)
OR odds ratio, CI confidence interval, BMI body mass index, OR operating room
a p values <0.05 are in bold. All variables on a significance level of p<0.2 in the univariate analysis were entered in the
multivariate analysis.
Table 4 Uni- and multivariate analysis of characteristics associated with wound infection (n =72)
Characteristic Wound infection Multivariate
OR p (95% CI) (%) Univariate, p Age, median(range) 58, (29-91) 0.031 1.02, 0.171 (0.99-1.04) Gender 0.207 Male 39/116 33.6 Female 33/126 26.2 Histology of primary 0.219 Superficial spreading 29 40.3 Nodular melanoma 17 23.6 Acrolentigenous 9 12.5 Unknown primary 4 5.6 Other 4 5.6 BMI 0.004 <25 21/98 21.4 1.00, 0.043 25-30 35/104 33.7 1.60, 0.158 (0.83-3.06) >30 16/34 47.1 2.93, 0.013 (1.26-6.85)
Smoking 0.252 - 56/176 31.8 + 16/66 24.2 ≥1 comorbidity 0.015 - 39/159 24.5 + 33/83 39.8 1.45, 0.268 (0.75-2.80) Operative time ≤130 minutes 31/117 26.5 > 130 minutes 41/125 32.8 0.284 OR year 0.785 1989-2000 16/63 25.4 2001-2005 22/80 27.5 2006-2011 22/69 31.9 2012-2014 12/30 40
Bohler Braun Splint 0.380
Yes 16/63 25.4 No 56/179 31.3 Bed in Linido 0.228 Yes 40/120 33.3 No 32/122 26.2 Type dissection 0.360 Superficial 5/12 41.7 Superficial+ deep 67/230 29.1 Indication 0.263 Micrometastasis 26/75 34.7 Macrometastasis 46/167 27.5
Total nodal yield 0.291
0-16 35/127 27.6
17-22 21/51 41.2
>22 11/34 32.4
BMI body mass index, OR operating room
a p values <0.05 are in bold. All variables on a significance level of p<0.2 in the univariate analysis were entered in the multivariate analysis.
The analysis showed a BMI higher than 30kg/m2 to be independently associated with WI, as shown in Table 4 OR2.93, p=0.013. Data on recurrence and survival were available for 182 patients, and 57 patients were lost to follow-up. The median MSS was worse for patients with a wound complication ( 27.4 months; range 18.9-35.9) compared to 88.8 months for patients without a wound complication, p=0.002. The median DFS was worse for the patients with a wound complication (10.5 months; range 6.7-14.4) compared to 30.6 months (range 13.7- 47.5), p=0.001. Median DFS for patients with a WI was also worse compared to patients without a WI, respectively 10.5 months (range 6.2-14.9) VS 21.9 months (range 11.5-32.3), p=0.006.
Discussion
In this retrospective observational study, the different adjustments treatment protocols have been studied over the years with regard to their influence on the occurrence of wound complications after an ILND.
Reducing postoperative bed rest did not influence the overall occurrence of wound complications in this study. Stuiver et al. in a study of 145 cases, found age to be the only predictor for a wound complication. Reducing the postoperative bed rest also did not influence the wound complication rate in their study. The other studied variables showed great similarity with those in the current study cohort. A difference however, was the variety of surgical techniques used by Stuiver et al.8 Due to the consistency
of the surgical procedure in our center, we are unable to determine whether changing this procedure would have led to a decrease in postoperative wound complications. In accordance to the results of Stuiver et al., earlier analysis of a smaller cohort (n=204) did not show an association between early mobilization and wound complications either.10 Reduction of bed rest significantly decreased hospital stay in this study , as
expected. This is in accordance with the literature.11 It seems safe to abolish the one
week strict bed rest. After the reduction of strict bed rest, the use of a Bohler Braun splint and the postural restrictions (bed positioned with elevated legs) were abolished from 2001 onward. Neither of these changes influenced the occurrence of wound
complications. After the postoperative changes, a pre-operative change was made with the introduction of prophylactic antibiotics before CLND from 2004 onward. This did not result in a reduction of the wound complication rates or a reduced WI rate. The addition of IHC staining over time, has led to an earlier detection of occult microscopic metastatic tumour cells.12 The relative overall increase in CLND’s might
also be explained by this change in guidelines. Our finding that a CLND versus a TLND does not influence the incidence of wound complications is in contradiction with findings in literature. Faries et al. stated that CLND was accompanied with less morbidity than TLND. This difference in morbidity could be explained by the difference in the extent of soft tissue dissection to clear the LN basin.13 Our results
show no difference between superficial and combined dissections in the incidence of wound complications. Due to the limited numbers of patients in the superficial group (n=12), no definitive conclusion can be drawn from these results. The institution of a door movement protocol in 2007 did not lead to a reduction of WIs. Knobben et al. performed a prospective trial in our center, where multiple behavioural changes (such as restriction of door movement) led to a significant reduction of WIs.14 Since
the introduction of the door movement protocol, no major changes have occurred in treatment protocols. Several patient specific factors such as BMI and age, do negatively influence the occurrence of wound complications, although these are not subject to intervention. Multivariate analysis revealed no association between the different patient characteristics, the different protocols and the occurrence of wound complications. The wound complication rate of 51.2% found in this study is in accordance with rates found in the recent literature.4,5,10,15 However, when
postoperative WIs were specifically investigated, BMI was associated with their occurrence. Our data show a WI rate of 29.8% compared to 45% by Stuiver et al. using the same definition.8 The majority of patients in this study were overweight
(57.3%). A trend to an increase in BMI was found in the most recent population with stage III melanoma. More than 25% of the patients in group D had a BMI higher than 30kg/m2 compared with approximately 10% in the remaining groups. The finding that BMI adds to the risk of developing WI is supported by the literature.4,6,10,11,16 The
heterogeneity in reported wound complication rates can probably be explained by variations in definitions used for WI worldwide.17 Due to its retrospective nature,
studies. As we know, immobilization increases the risk on thromboembolic events and in particular in a population with a high BMI.18-22 Especially in these high risk
patients, early mobilization is of utmost importance. Our data support this as we observed no thromboembolic events in the group with a short period of bed rest. The significant increase in nodal yield over the years is indicative for the success of standardized surgical and pathological procedures.
Several authors report the use of incisional negative pressure wound therapy (INPWT) to prevent WIs at surgical sites, including inguinal incisions.23 Prospectively
randomized studies concerning application and cost-effectiveness of INPWT in oncologic procedures such as an ILND are scarce. Nevertheless, there might be a role for INPWT after ILND in the future.
In conclusion, over the past decades several adjustments have been made in treatment protocols for patients undergoing an ILND. To date, none of these adjustments have led to a substantial reduction in wound complications at the UMCG. However, we learned that bed rest and, with that, hospital admission can be reduced. In general, we can state that when performing inguinal lymphadenectomies in patients with stage III melanoma at the UMCG, the occurrence of wound complications for about 50% of the patients cannot be avoided to date. Managing the postoperative patient after ILND with the aim to prevent wound complications, remains a challenge, especially taking into account the negative influence of higher age and obesity on the occurrence of wound complications, and their expected increase in the future.24
An ILND is a potentially curative surgical procedure and wound complications can hinder the most adequate treatment, as radiotherapy can be postponed or even abandoned due to wound problems. Furthermore, our results show that both DFS and MSS are significantly worse when a WI occurs. Preventing wound complications is of the essence.
The inability to reduce the incidence of wound complications over the years calls for drastic measures. The most consistent variable over the years, has been the surgical procedure itself. Replacement of the large inguinal incision by three smaller incisions away from the inguinal skin fold might offer a solution via a minimal invasive technique: videoscopic inguinofemoral lymphadenectomy.
This procedure is accompanied with a lower complication rate in other centres and has a comparable oncologic outcome.25-27 Because all other adjustments in perioperative care
and management have failed, this procedure might be a promising method for reducing wound complications after ILNDs. The authors have started a trial to study the effect of videoscopic inguinofemoral lymphadenectomy on postoperative complications, lymph edema and quality of life. The first results are expected by early 2017.
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